DAMAS HOSPITAL SNF
Non profit - Corporation
25 Beds
Independent
Data: November 2025
Trust Grade
63/100
#2 of 6 in PR
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Damas Hospital SNF has a Trust Grade of C+, indicating it's slightly above average but not without issues. Ranked #2 out of 6 facilities in Puerto Rico, it sits in the top half, and it is the only option in Ponce County. The facility is improving, with issues decreasing from 20 in 2024 to 10 in 2025. Staffing is a strength, earning a perfect 5/5 stars with a 32% turnover rate, which is average for the area. However, the facility has concerning fines totaling $10,839, higher than 77% of similar facilities. While there is good RN coverage, being better than 85% of Puerto Rico facilities, there are some troubling incidents. A serious finding revealed that the facility failed to report incidents of neglect promptly, which could hinder proper corrective actions. Additionally, multiple residents reported dissatisfaction with their meals, including issues with food preferences not being met and food safety concerns observed in the kitchen, such as improperly stored chicken and rust in the meat freezer. Overall, families should weigh these strengths and weaknesses carefully when considering this nursing home.
- Trust Score
- C+
- In Puerto Rico
- #2/6
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 32% turnover. Near Puerto Rico's 48% average. Typical for the industry.
- Penalties ✓ Good
- $10,839 in fines. Lower than most Puerto Rico facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 253 minutes of Registered Nurse (RN) attention daily — more than 97% of Puerto Rico nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 38 deficiencies on record. Higher than average. Multiple issues found across inspections.
63/100
Top 33%
Needs review
20 → 10 violations
★★★★☆
4.0
Overall Rating
★★★★★
5.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 20 issues
2025: 10 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (32%)
16 points below Puerto Rico average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
Staff Turnover: 32%
14pts below Puerto Rico avg (46%)
Typical for the industry
Federal Fines: $10,839
Below median ($33,413)
Minor penalties assessed
The Ugly 38 deficiencies on record
1 actual harm
Mar 2025
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and records reviewed (RR), it was determined that the facility failed to complete the Comprehensive Minim...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and records reviewed (RR), it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS) assessment in a timely manner for one resident. This deficient practice was identified for 1 of 12 residents reviewed for MDS assessments. (Resident #513).
Findings include:
1. During initial pool on 03/27/2025 at 8:30 AM resident 513 is visited who is a female admitted on [DATE] for left artificial knee replacement and a Continuous Positive Airway Pressure (CPAP) machine is observed in the room. By interviewing the resident, she indicates that she has been using CPAP for a diagnosis of sleep apnea since 2018 and has always used the same machine. She indicates that her husband brought her the machine in a bag, but the nursing or medical staff were notified that she had that diagnosis and needed the machine to sleep. The resident refers that she took the CPAP out to use on the night of March 26, 2025, and realized that the machine was not working.
2. During the R.R. 513 on 03/27/2025 at 11:20 AM it is noted that the initial care plan did not include the diagnosis of sleep apnea or the need for a CPAP.
3. The facility failed to perform a proper comprehensive assessment that identified all the residents' diagnoses and needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of twelve medical records, resident interview and interview with the Respiratory Therapy Director (employee #1) ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of twelve medical records, resident interview and interview with the Respiratory Therapy Director (employee #1) performed from 03/27/2025 thru 03/28/2025, from 8:00 AM thru 4:00 PM, it was determined that the facility failed to develop and implement baseline care plan within 48 hours of a resident's admission in order to promote the continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services. This deficient practice was identified in 1 out of 12 records reviewed (RR). (RR #513)
Findings include:
1. During initial pool on 03/27/2025 at 8:30 AM resident 513 is visited who is a female admitted on [DATE] for left artificial knee replacement and a Continuous Positive Airway Pressure (CPAP) machine is observed in the room. By interviewing the resident, she said that she has been using CPAP for a diagnosis of sleep apnea since 2018 and has always used the same machine. She indicates that her husband brought her the machine in a bag, but the nursing or medical staff were notified that she had that diagnosis and needed the machine to sleep. The resident refers that she took the CPAP out to use on the night of March 26, 2025, and realized that the machine was not working.
2. During upon file review on 03/27/2025 at 11:20 AM it is noted that the baseline care plan within 48 hours did not include a care plan for respiratory care or use of the CPAP machine.
3. In an interview with the respiratory therapy director on 03/28/25 at 11:02 AM, he indicated that in cases of patients with respiratory needs, they oversee carrying out the care plan once they receive the medical order from the internal doctor or nursing recommendation. They could supply the equipment with what they have available in the hospital, but since they do not have the parameters available and the machine does not adjust to the residents' preferences since it has a mask and not a nasal cannula, it is a little complicated for them.
4. The facility failed to conduct and document a baseline care plan during the first 48 hours of admission that included actions to be taken to address the residents' needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, twelve records reviewed (RR) and interviews with the Director of Respiratory Therapy (employee #1) and th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, twelve records reviewed (RR) and interviews with the Director of Respiratory Therapy (employee #1) and the Supervisor of Respiratory Therapy (employee #9), it was determined that facility failed to have the capability to provide needed respiratory care/services to residents with respiratory diagnosis that requires specialized respiratory care and/or services. This deficient practice affects 1 out of 14 sample cases (SC) receiving services. (SC#513)
Findings include:
1. During initial pool on 03/27/2025 at 8:30 AM resident 513 is visited who is a female admitted on [DATE] for left artificial knee replacement and a Continuous Positive Airway Pressure (CPAP) machine is observed in the room. By interviewing the resident, she said that she has been using CPAP for a diagnosis of sleep apnea since 2018 and has always used the same machine. She indicates that her husband brought her the machine in a bag, but the nursing or medical staff were not notified that she had that diagnosis and needed the machine to sleep. The resident refers that she took the CPAP out to use on the night of March 26, 2025, and realized that the machine was not working.
2. In an interview with the respiratory therapy director on 03/28/25 at 11:02 AM, he indicated that in cases of patients with respiratory needs, they oversee carrying out the care plan once they receive the medical order from the internal doctor or nursing recommendation. They could supply the equipment with what they have available in the hospital, but since they do not have the parameters available and the machine does not adjust to the patient's preferences since it has a mask and not a nasal cannula, it is a little complicated for them.
3. The respiratory therapy supervisor was interviewed on 03/28/2025 at 11:50 AM and reported that on 03/27/2025 all the pertinent steps were taken to address the diagnosis of resident 513, however, when calling the resident's pulmonologist, he told her that the resident had not attended a follow-up visit for two years, so he could not provide her with the parameters to be performed since she would have to undergo the sleep study again.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment and facility staff interview performed on 03/27/2025 from 8:00 AM through 4:00...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment and facility staff interview performed on 03/27/2025 from 8:00 AM through 4:00 PM, it was determined that the facility failed maintain an effective pest control program so that the facility is free of pests.
Findings include:
1. During the observations performed in the resident's rooms, with Physical Plant Director employee (#10) the following was observed:
a) On 03/27/2025 at 9:15 AM spider was observed behind curtains in room [ROOM NUMBER].
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment and facility staff interview performed on 03/27/2025 from 8:00 AM through 4:00...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment and facility staff interview performed on 03/27/2025 from 8:00 AM through 4:00 PM, it was determined that the facility failed to promote the resident right to receive service in a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. This deficient practice was observed on 8 out of 9 rooms at the facility visited.
Findings include:
1. During the observations performed in the residents' rooms, with Physical Plant Director employee (#10) the following was observed:
a) On 03/27/2025 from 9:00 AM through 9:40 AM it was observed the nightstands had parts of the plastic cover exposed in rooms #309, #311, #318 and #319.
b) On 03/27/2025 from 9:10 AM through 9:40 AM it was observed the armchairs had armrest deteriorated in rooms #309, #311, #314 and #316.
c) On 03/27/2025 at 9:40 AM it was observed the table tray is uneven in room [ROOM NUMBER].
d) On 03/27/2025 at 9:51 AM no cord was available to turn on the light.
e) On 03/27/2025 from 9:00 AM through 9:35 AM it was observed the bathroom grab bars were unsafe and loose in rooms #310, #311, #314, #315, #316 and #319.
f) On 03/27/2025 at 9:35 AM it was observed mold in the bathroom faucet area of in room [ROOM NUMBER].
g) On 03/27/2025 at 9:32 AM it was observed deteriorated floor in room [ROOM NUMBER].
h) On 03/27/2025 from 9:00 AM through 9:40 AM it was observed parts of the floor baseboard to be detached and deteriorated in rooms #309, #314, #315 and #319.
i) On 03/27/2025 at 9:32 AM, it was observed areas behind the chairs and beds were observed to littered with dirt and trash in rooms #315, #316 and #318.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected most or all residents
Based on dining observations, review of policies procedures and facility staff interview performed on 03/27/25, it was determined that the facility failed to ensure that each resident receives food th...
Read full inspector narrative →
Based on dining observations, review of policies procedures and facility staff interview performed on 03/27/25, it was determined that the facility failed to ensure that each resident receives food that accommodates resident allergies, intolerances, and preferences. This deficiency was identified in 3 out of 21 residents of the sample selection receiving services (Residents #162, #163, #314).
Findings include:
1. Resident # 314 does not take instant coffee, prefers to be prepared traditionally this was not provided.
2. Resident #162 referred to hot cereal was not palatable for her needs, she was provided with unsweetened hot cereal which she could not eat because of the flavor.
3. Resident #163 said the meat she was served was dry and was not palatable for her preference.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 03/27/25, it was determined that the facility failed to store, prepare, distribute and ser...
Read full inspector narrative →
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 03/27/25, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Findings include:
1. During the visual inspection of the kitchen area it was observed that Chicken was held on temperature of 132 degrees Fahrenheit on serving container on line prep not reaching the required temp of 165 degrees Fahrenheit for poultry.
2. Meat freezer floor was observed uneven and with broken cement in entrance permitting mold and ice to develop.
3. Holding racks in meat freezer were observed with rust in tubing.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected most or all residents
Based on review of policies, procedures and facility staff interview performed on 03/27/25, it was determined that the facility failed to comply with the policy regarding use and storage of foods brou...
Read full inspector narrative →
Based on review of policies, procedures and facility staff interview performed on 03/27/25, it was determined that the facility failed to comply with the policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.
Findings include:
During observation of the residents refrigerator a unlabeled yougurt and ice cream were found.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 03/27...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 03/27/2025 through 03/28/2025 from 8:00 AM through 4:00 PM, it was determined that the facility failed with the use of standards practice for prevention and requirements for temperature recording which could promote deterioration of the supply or the spread of microorganisms. This deficient practice could affect 21 out of 21 residents admitted receiving care at the facility.
Findings include:
The MDS Coordinator (employee #4) provided facility's policy and procedure last update on 02/2025 for Registro de Temperatura y Humedad en Almacenes de Suplidos de Materiales Médico Quirúrgicos. It was reviewed on 03/27/2025 at 1:45 PM. States that the air conditioning system temperature parameters, according to the standard, are 70°F to 75°F. In the procedure area. In section 2, it states that the physical plant will be notified if the temperature is not within the appropriate parameters and their action will be documented.
1.During the tour of the facility's storage performed on 03/27/2025 at 1:20 PM, and interview with MDS Coordinator (employee #4), it was observed that medical-surgical material storage had a temperature of 69.3°F. The daily temperature record for the month of March was observed and for this day the reading was 68.6°F, no written action taken by personnel was observed.
2. It was observed in the daily temperature records that in the months of January, February and March the temperature fluctuated between 66.1°F to 69.5°F and no written action taken by personnel was observed for these months.
5. During the medication pass performed on 03/27/2025 from 12:52 PM to 1:18 PM with the registered nurse (employee #7) it was observed that the nurse fails 6 of 12 opportunities to perform hand hygiene.
6. During the medication pass performed on 03/28/2025 from 7:57 AM to 8:10 AM with the registered nurse (employee #8) it was observed that the nurse fails 2 of 6 opportunities to perform hand hygiene.
3. During the observations made in the wound treatment procedures by the Orthopedic Technician employee #6 on 03/28/2025 at 9:00 AM to 10:00 AM, the following were observed:
a. Resident #211 is a [AGE] year-old male admitted on [DATE] with Right hip Osteoarthritis/TKR.
The Orthopedic Technician employee #6 was observed providing skin wound care.
When she went to change the bandages did not wash her hands with soap and water or hand sanitizer.
At the time of disinfecting the wound, gloves were changed, but hands were not disinfected with soap and water or hand sanitizer.
She changes gloves without washing hands with soap and water or hand sanitizer before applying Xeroform (Vaseline gauze).
The Director of Nursing (DON) was interviewed on 03/28/2025 at 11:30 AM, she referred to not having a policy created on the management in the Skilled Nursing area by the Orthopedic Technician.
The Orthopedic Technician job description provided by the supervisor talks about treatments and changing dressings on orthopedic surgery residents, but the facility has not created policies and procedures on how they are going to proceed at the time of a wound treatment on residents.
4. During the round provided in the rooms with the Physical Plant Manager employee #10 on 3/27/2025 from 8:00 AM to 3:00 PM, the following was observed:
The Supervisor (employee #2) provided facility's policy and procedure last update on 02/2025 for Reemplazo Filtros de Ductos de Aire Acondicionado. Replacement of Filter of the Ducts of the Air Condition Procedure: 2. The physical plant personnel will replace the air duct filters monthly. 6. The cleaning staff will clean the grill.
a. The air conditioning inlet grill compartments were observed to be dusty in rooms #309, #310, #311.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observations of the rooms, review of policies procedures and facility staff interview performed on 03/27/2025 from 8:00 AM through 3:00 PM, it was determined that the facility did not meet th...
Read full inspector narrative →
Based on observations of the rooms, review of policies procedures and facility staff interview performed on 03/27/2025 from 8:00 AM through 3:00 PM, it was determined that the facility did not meet the requirements for sanitation of the air conditioner inlet grill compartment for 3 out of 3 residents' rooms.
Findings include:
The Supervisor (employee #2) provided facility's policy and procedure last update on 02/2025 for Reemplazo Filtros de Ductos de Aire Acondicionado. Replacement of Air Conditioning Duct Filters. Procedure: 2. The physical plant personnel will replace the air duct filters monthly. 6. The cleaning staff will clean the grill.
1. During the round provided in the rooms with the Physical Plant Manager employee #10 on 3/27/2025 from 8:00 AM to 3:00 PM, the following was observed:
a. The air conditioning inlet grille compartments were observed to be dusty in rooms #309, #310, #311.
Oct 2024
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that the abuse and neglect and the Han...
Read full inspector narrative →
Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that the abuse and neglect and the Hand in Hand trainings were provided to all employees of the Skilled Nursing Facility (SNF) and ensure employees are knowledgeable to react and respond appropriately to protect the resident's right to be free from mental abuse. This deficient practice was identified in 7 out of 22 credential files reviewed to investigated compliance with training requirements. ( CF # 11,#12,#13,#14,#15, #16, and #17).
Findings include:
During the review of SNF employee Abuse and neglected and the Hand in Hand Trainings on 10/30/2024 from 1:00 PM till 2:00 PM, 7 out of 22 (31.8%) of nursing personnel working in the SNF did not complete the hand in hand training.
1.Review of 22 Credential file Review (CFR) on 10/30/2024 at 2:00 PM it was found that
These employees took modules 1, module 2 and module 3; they did not complete module 4 Being with a person with Dementia: Making a Difference and module 5 Preventing and Responding to Abuse. This nursing personnel took these two modules in 2023.
The Hand-in- Hand -A training Series for Nursing Home was taken by an e-learning computer training system that individualized virtual training that the personnel take when they have time to complete the module at different times in the years.
a.CFR #11 took the Hand -in- Hand -A training Series for Nursing Home
Module #1 Understanding the word Dementia: The person and the disease, was taken on 08/17/2024 and take 3 minutes with 30 seconds to complete them with 100% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking, taken on 08/17/2024 and take 3 minutes with 23 seconds to complete them with 100% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions on 08/17/2024 and take 3 minutes with 01 seconds to complete them with 100% qualification in the SNF.
Module #4 Being with a person with Dementia: Making Difference, taken on 11/08/2023 and take 2 minutes with 15 seconds to complete them with 100% qualification in the maternal and child floor and Nineth floor that was medicine and isolation.
Module #5 Preventing and Responding to abuse taken on 11/08/2023 and takes 2 minutes with 27 seconds to complete them with 100% and qualification in the maternal and child floor and Nineth floor that was medicine and isolation.
This employe was transferred from Hospital setting to the SNF on 06/24/2024.
b. CFR #12 took the Hand -in- Hand -A training Series for Nursing Home
Module #1 Understanding the word of Dementia: The person and the disease, taken on 05/06/2024 and take 2 minutes with 48 seconds to complete them with 90% qualification while at the Hospital Setting.
Module #2 Being with a person with Dementia: Listening and Speaking, taken on 05/06/2024 and take 2 minutes with 43 seconds to complete them with 80% qualification while at Hospital Setting.
Module #3 Being with a person with Dementia: Actions and Reactions, taken on 05/06/2024 and take 3 minutes with 38 seconds to complete them with 100% qualification while at Hospital Setting.
Module #4 Being with a person with Dementia: Making Difference, taken on 11/29/2023 and take 5 minutes with 11 seconds to complete them with a 75% qualification while at the Hospital Setting.
Module #5 Preventing and Responding to abuse, taken on 11/29/2023 and take 2 minutes with 35 seconds to complete them with 87.50% qualification in Hospital Setting.
This employe was transferred from Hospital setting to the SNF on 07/09/2024.
c. CFR #13 take the Hand -in- Hand -A training Series for Nursing Home
Module #1 Understanding the word of Dementia: The person and the disease: taken on 07/20/2024 and take 36 seconds to complete them with a 90% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking; taken on 07/20/2024 and take 43 seconds to complete them with a 80% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions; taken on 07/20/2024 and take 46 seconds to complete them with 90% qualification in the SNF.
Module #4 Being with a person with Dementia: Making Difference taken on 07/29/2023 and take 49 seconds to complete them with a 87.50% qualification in the SNF.
Module #5 Preventing and Responding to abuse; taken on 07/29/2023 and take 2 minutes with 36 seconds to complete them with a 100% qualification in the SNF.
d. CFR #14 take the Hand -in- Hand -A training Series for Nursing Home
Module #1 Understanding the word of Dementia: The person and the disease; taken on 04/13/2024 and take 1 minute with 45 seconds to complete them with 100% qualification in Hospital Setting.
Module #2 Being with a person with Dementia: Listening and
Speaking; taken on 04/13/2024 and take 2 minutes with 03 seconds to complete them with 100% qualification in Hospital Setting.
Module #3 Being with a person with Dementia: Actions and Reactions, taken on 04/13/2024 and take 1 minute with 52 seconds to complete them with 100% qualification in Hospital Setting.
Module #4 Being with a person with Dementia: Making Difference; taken on 03/27/2023 and take 48 seconds to complete them with 100% qualification in the Hospital Setting.
Module #5 Preventing and Responding to abuse; taken on 03/27/2023 and take 24 seconds to complete them with 100% qualification in Hospital Setting.
This employe was removed from Hospital setting to the SNF on 06/10/2024.
e. CFR #15 take the Hand-in- Hand -A training Series for Nursing Home:
Module #1 Understanding the word of Dementia: The person and the disease; taken on 10/16/2024 and take 1 minute with 40 seconds to complete them with 80% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking; taken on 05/18/2023 and take 1 minute with 15 seconds to complete them with 90% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions: taken on 05/18/2023 and take 1 minute to complete them with 80% qualification in the SNF.
Module #4 Being with a person with Dementia: Making Difference; taken on 12/01/2023 and take 1 minute with 58 seconds to complete with 100% qualification in the SNF.
Module #5 Preventing and Responding to abuse, taken on 12/01/2023 and take 6 minutes with 48 seconds to complete them with 100% qualification in the SNF.
f. CFR #16 take the Hand -in- Hand -A training Series for Nursing Home:
Module #1 Understanding the word Dementia: The person and the disease; taken on 09/28/2024 and take 6 minutes with 17 seconds to complete them with 100% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking; taken on 09/28/2024 and take 3 minutes with 49 seconds to complete them with 100% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions on 09/28/2024 and take 3 minutes with 43 seconds to complete them and qualification 100% in the SNF.
Module #4 Being with a person with Dementia: Making Difference on 03/22/2023 and taking 7 minutes with 14 seconds to complete them with 100% qualification in the SNF.
Module #5 Preventing and Responding to abuse; taken on 03/22/2023 and take 1 minute with 50 seconds to complete them with 100% qualification in the SNF.
g. CFR #17 take the Hand-in- Hand -A training Series for Nursing Home:
Module #1 Understanding the word Dementia: The person and the disease; taken on 09/04/2024 and take 4 minutes with 14 seconds to complete them with 90% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking; taken on 09/04/2024 and take 4 minutes with 35 seconds to complete them with 90% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions; taken on 09/04/2024 and 31 seconds to complete them with 30% qualification in the SNF.
Module #4 Being with a person with Dementia: Making Difference; taken on 11/22/2023 and taking 19 minutes with 16 seconds to complete them with 75% qualification in Hospital setting.
Module #5 Preventing and Responding to abuse; taken on 11/22/2023 and take 1 minute with 49 seconds to complete them with 87.50% qualification in Hospital setting.
This employe was removed from the Hospital setting and transferred to the SNF on 05/25/2024.
2.The facility failed to ensure to provide to all employees of the SNF with the Hand -in- Hand -A training Series for Nursing Home 5 module in sequence time during the years and ensure that the employees are knowledgeable to react and respond appropriately to protect the residents' rights.
3. During an interview with the associated DON (employee #1) on 10/30/2024 at 3:00 PM she states that the facility provides to the nursing personnel education relates to abuse and neglect by e-learning computer education system and the hand in hand training by e-learning annual. That in September 2024, they provide the abuse and neglect training presential.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Employment Screening
(Tag F0606)
Could have caused harm · This affected 1 resident
Based on review of facility Self-Reported incident, interviews with facility nursing supervisor and human resource officials and review of policies and procedures performed on 10/30/2024 at 11:00 AM, ...
Read full inspector narrative →
Based on review of facility Self-Reported incident, interviews with facility nursing supervisor and human resource officials and review of policies and procedures performed on 10/30/2024 at 11:00 AM, it was determined that the facility failed to maintain an exhaustive screening process before an employee is assigned to provide direct care to residents and form part of the facility direct care personnel. This deficient practice was identified in 2 out of 7 complaints investigated with potential abuse and neglect incidents.
Findings include:
Review of the facility's policy Title Abuse and Neglect effective in May 2023, policy clearly stated that it is the responsibility of the facility to screen all potential employees in relation to abuse and neglect. Policy includes provisions to be followed to ensure that diligent process must be implemented to assure history of the potential employee behavior on previous work scenario is considered before is sent to the area from which is being considered.
1. The facility report to the Puerto Rico State Agency(PRSA) Medicare Division an incident related to two suspected abuse and neglect event incidents occurred on 10/20/2024. While investigated on 10/29/2024 this incident at the facility the following was identified:
a. Incident reported by facility as occurred on 10/20/2024, involves the participation of a Licensed Practical Nurse (LPN). Accordingly with the information included in the investigation of this incident performed by facility and reported to the PRSA Medicare division on 10/25/2024 the LPN involved in the incident had been previously reoriented in relation to abuse and neglect requirements and protocols.
b. When the surveyor asked the facility Director of Nursing (DON) (employee #1) on 10/30/2024 at 10:25 AM, the reason why it is not included in the investigation of this case was that this LPN had been previously reoriented in relation to abuse and neglect requirements and protocols. She explains that this LPN used to work at the facility hospital, (the Skilled Nursing Facility (SNF) is a hospital-based facility) 25 years ago and was transferred to the SNF to take part in resident's direct care in June 2024.
It was explained by the DON on 10/31/2024 at 11:00 AM that this LPN was involved in 2 incidents related to abuse and neglect while providing services on the maternity ward on January 23, 2018, and July 22, 2023, respectively.
The DON explained that both incidents were related to circumstances where the LPN did not maintain emphatic communication and an approach to patients that receive services at the maternity ward.
The facility documented both events and re-oriented this LPN in relation to abuse and neglect requirements and protocols. DON stated that in the year 2024 this LPN begins to show interest in being transferred to the SNF to form part of the SNF employee staff.
The surveyors asked the DON if both those incidents occurred previously on January 23, 2018, and July 22, 2023, respectively were taking into consideration before granting the opportunity to this LPN to form part of the SNF employee staff. The DON respond that those incidents were considered before granted the opportunity to this LPN to form part of the SNF employee staff.
c. The SNF Nursing Supervisor (employee #2) was interviewed on 10/30/2024 at 10:10 AM and was asked by the surveyor if she knows if the LPN allegedly was involved in the incident that occurred on 10/20/2024 has previous history of non-compliance with abuse and neglect protocol requirements.
The SNF Nursing Supervisor stated on 10/30/2024 at 10:12 AM that she believes that there is previous history, but she does not have the details. She stated that she was not consulted, informed or asked previously to transfer this LPN to her employee staff personnel on the month of June 2024. She also stated that when an employee that is working on the hospital is going to be considered to take part in the SNF staff; the screening process is less rigorous that the screening process when new hire personnel is considered to be part of the SNF staff.
d. Human Resource official (employee #9) and Director (employee #7) was asked by the surveyor on 10/30/2024 at 10:45 AM if the screening process of potential employees considered to take part of SNF staff when proceed from their same hospital is less rigorous that the screening process performed to potential employees considered to take part of SNF staff when is a new hire.
The Human Resource Director stated on 10/30/2024 at 11:05 AM that the screening process varies when the staff proceed from their same hospital, because facility honor seniority who are privileged rank based on continuous employment with the facility. He explains that they consider this personnel interest to take part of facility staff of other areas, and review personnel competence, but it is not so extremely thorough exhaustive than the system when is new hire personnel considered to take part of the SNF staff.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that the abuse and neglect training an...
Read full inspector narrative →
Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that the abuse and neglect training and the Hand in Hand training was provided to all employees of the Skilled Nursing Facility (SNF) and ensure employees are knowledgeable to react and respond appropriately to protect the resident's right to be free from mental abuse.
Findings include:
During the review of SNF employee Abuse and neglected training and the Hand in Hand Training on 10/30/2024 at 1:00 pm, the following was found:
1.Review of 22 Credential file Review (CFR) on 10/30/2024 at 2:00 PM it was found that 7 out of 22 (31.8%) of nursing personnel working in the SNF did not complete the hand in hand training.
These employees took modules 1, module 2 and module 3; they did not complete module 4 Being with a person with Dementia: Making a Difference and module 5 Preventing and Responding to Abuse. This nursing personnel took these two modules in 2023.
The Hand-in- Hand -A training Series for Nursing Home was taken by an e-learning computer training system that individualized virtual training that the personnel take when they have time to complete the module at different times in the years.
a.CFR #11 took the Hand -in- Hand -A training Series for Nursing Home
Module #1 Understanding the word of Dementia: The person and the disease, was taken on 08/17/2024 and take 3 minutes with 30 seconds to complete them with 100% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking, taken on 08/17/2024 and take 3 minutes with 23 seconds to complete them with 100% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions on 08/17/2024 and take 3 minutes with 01 seconds to complete them with 100% qualification in the SNF.
Module #4 Being with a person with Dementia: Making Difference, taken on 11/08/2023 and take 2 minutes with 15 seconds to complete them with 100% qualification in the maternal and child floor and Nineth floor that was medicine and isolation.
Module #5 Preventing and Responding to abuse taken on 11/08/2023 and takes 2 minutes with 27 seconds to complete them with 100% and qualification in the maternal and child floor and Nineth floor that was medicine and isolation.
This employe was transferred from Hospital setting to the SNF on 06/24/2024.
b. CFR #12 took the Hand -in- Hand -A training Series for Nursing Home
Module #1 Understanding the word of Dementia: The person and the disease, taken on 05/06/2024 and take 2 minutes with 48 seconds to complete them with 90% qualification while at the Hospital Setting.
Module #2 Being with a person with Dementia: Listening and Speaking, taken on 05/06/2024 and take 2 minutes with 43 seconds to complete them with 80% qualification while at Hospital Setting.
Module #3 Being with a person with Dementia: Actions and Reactions, taken on 05/06/2024 and take 3 minutes with 38 seconds to complete them with 100% qualification while at Hospital Setting.
Module #4 Being with a person with Dementia: Making Difference, taken on 11/29/2023 and take 5 minutes with 11 seconds to complete them with a 75% qualification while at the Hospital Setting.
Module #5 Preventing and Responding to abuse, taken on 11/29/2023 and take 2 minutes with 35 seconds to complete them with 87.50% qualification in Hospital Setting.
This employe was transferred from Hospital setting to the SNF on 07/09/2024.
c. CFR #13 take the Hand -in- Hand -A training Series for Nursing Home
Module #1 Understanding the word of Dementia: The person and the disease: taken on 07/20/2024 and take 36 seconds to complete them with a 90% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking; taken on 07/20/2024 and take 43 seconds to complete them with a 80% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions; taken on 07/20/2024 and take 46 seconds to complete them with 90% qualification in the SNF.
Module #4 Being with a person with Dementia: Making Difference taken on 07/29/2023 and take 49 seconds to complete them with a 87.50% qualification in the SNF.
Module #5 Preventing and Responding to abuse; taken on 07/29/2023 and take 2 minutes with 36 seconds to complete them with a 100% qualification in the SNF.
d. CFR #14 take the Hand -in- Hand -A training Series for Nursing Home
Module #1 Understanding the word of Dementia: The person and the disease; taken on 04/13/2024 and take 1 minute with 45 seconds to complete them with 100% qualification in Hospital Setting.
Module #2 Being with a person with Dementia: Listening and
Speaking; taken on 04/13/2024 and take 2 minutes with 03 seconds to complete them with 100% qualification in Hospital Setting.
Module #3 Being with a person with Dementia: Actions and Reactions, taken on 04/13/2024 and take 1 minute with 52 seconds to complete them with 100% qualification in Hospital Setting.
Module #4 Being with a person with Dementia: Making Difference; taken on 03/27/2023 and take 48 seconds to complete them with 100% qualification in the Hospital Setting.
Module #5 Preventing and Responding to abuse; taken on 03/27/2023 and take 24 seconds to complete them with 100% qualification in Hospital Setting.
This employe was removed from Hospital setting to the SNF on 06/10/2024.
e. CFR #15 take the Hand-in- Hand -A training Series for Nursing Home:
Module #1 Understanding the word of Dementia: The person and the disease; taken on 10/16/2024 and take 1 minute with 40 seconds to complete them with 80% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking; taken on 05/18/2023 and take 1 minute with 15 seconds to complete them with 90% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions: taken on 05/18/2023 and take 1 minute to complete them with 80% qualification in the SNF.
Module #4 Being with a person with Dementia: Making Difference; taken on 12/01/2023 and take 1 minute with 58 seconds to complete with 100% qualification in the SNF.
Module #5 Preventing and Responding to abuse, taken on 12/01/2023 and take 6 minutes with 48 seconds to complete them with 100% qualification in the SNF.
f. CFR #16 take the Hand -in- Hand -A training Series for Nursing Home:
Module #1 Understanding the word Dementia: The person and the disease; taken on 09/28/2024 and take 6 minutes with 17 seconds to complete them with 100% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking; taken on 09/28/2024 and take 3 minutes with 49 seconds to complete them with 100% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions on 09/28/2024 and take 3 minutes with 43 seconds to complete them and qualification 100% in the SNF.
Module #4 Being with a person with Dementia: Making Difference on 03/22/2023 and taking 7 minutes with 14 seconds to complete them with 100% qualification in the SNF.
Module #5 Preventing and Responding to abuse; taken on 03/22/2023 and take 1 minute with 50 seconds to complete them with 100% qualification in the SNF.
g. CFR #17 take the Hand-in- Hand -A training Series for Nursing Home:
Module #1 Understanding the word Dementia: The person and the disease; taken on 09/04/2024 and take 4 minutes with 14 seconds to complete them with 90% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking; taken on 09/04/2024 and take 4 minutes with 35 seconds to complete them with 90% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions; taken on 09/04/2024 and 31 seconds to complete them with 30% qualification in the SNF.
Module #4 Being with a person with Dementia: Making Difference; taken on 11/22/2023 and taking 19 minutes with 16 seconds to complete them with 75% qualification in Hospital setting.
Module #5 Preventing and Responding to abuse; taken on 11/22/2023 and take 1 minute with 49 seconds to complete them with 87.50% qualification in Hospital setting.
This employe was removed from the Hospital setting and transferred to the SNF on 05/25/2024.
2. Facility failed to ensure to provide to all employees of the SNF with the Hand -in- Hand -A training Series for Nursing Home 5 module in sequence time during the years and ensure that the employees are knowledgeable to react and respond appropriately to protect the residents' rights.
3. Facility failed to ensure that all employees of the SNF with the abuse and neglect training acquired the knowledge to react and respond appropriately to protect the residents' rights.
4. During an interview with the associated DON (employee #1) on 10/30/2024 at 3:00 PM she states that the facility provides to the nursing personnel education relates to abuse and neglect by e-learning computer education system and the hand in hand training by e-learning annual. That in September 2024, they provide the abuse and neglect training presential.
5. No evidence was found during the compliant investigation survey Medicare Division Surveyors and Federal surveyors for a Resource and Support Survey (RSS) on October 29, 2024, through October 30, 2024, from 8:00 AM through 4:30 PM; that facility establishes and maintains communication and coordination with the Quality Assessment Performance Improvement Program to provide protection of the rights of the residents when alleged incidents of abuse and neglect were suspected, investigated and managed.
6. During an interview on 10/30/2024 at 3:00 PM with the coordinator of resident's experience and complaint management officer (employee #6) stated that she reports and response directly to administration in relation of complaints and resident satisfaction.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on interview with the Director of nursing (employee #1) and Nursing supervisor (employee #2 )on 10/29/2024 through 10/30/2024 from 8:00 AM to 4:00 PM, it was determined that the facility failed ...
Read full inspector narrative →
Based on interview with the Director of nursing (employee #1) and Nursing supervisor (employee #2 )on 10/29/2024 through 10/30/2024 from 8:00 AM to 4:00 PM, it was determined that the facility failed to provide evidence that have and maintain sufficient nursing staff sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.
Findings include:
1.Director of Nursing (DON) was interviewed on 10/29/2024 at 1:00 PM and was asked by the surveyor for the categorization of residents admitted to the facility, the day alleged incidents of abuse and neglect occur on 10/20/2024.
DON was asked in relation to the quantity of nursing personnel (License Practical Nurse- LPN's & Registered Nurse- RN's) assigned to be in charge of resident's care and distribution accordingly with residents categorization and needs.
The DON stated during interview on 10/29/2024 at 1:30 PM that accordingly with resident categorization performed with a nurse leader in charge of this process on Sunday 20, 2024 the quantity of personnel required for a census of 19 residents, it is 3 LPN's to be assigned in charge of vital signs measure, bath assistance, feeding assistance, grooming assistance and other direct care duties and 2 Register nurses to be in charge of residents assessments, implementation of care plans and other skilled services. This implied a total of hours required of 4.5.
The DON proceeds to explain that on 10/20/2024 that it was Sunday and on this 7-3 shift and based on needs on the hospital's nine floor that is the medicine ward, one of the LPNs from the SNF was moved to the 9th floor. The general nursing supervisor assigned one of the three nurses that had been planned to provide services to the SNF residents, to the 9th hospital floor medicine ward; the nurse moved to the 9th floor was an LPN nurse.
The surveyor asked the DON if the movement of an LPN to the 9th floor did not affect the staffing calculated based on the needs of residents of the SNF. The DON explains that there is occasions were the calculation of staff required, takes up to a number to be sure that provider must comply with provision of services based of residents, but there are occasions in which residents that have advance in outcomes and plan of care goals and are most independent than other residents and this could implied a total of hours required of 3.5, she explain this was not necessarily reflected in the categorization calculus. She stated that there is the possibility that the calculation established be less (3.5).
In this case or situation on 10/20/2024 two nurses assigned to provide be assigned in charge of vital signs measure, bath assistance, feeding assistance, grooming assistance and other direct care duties, could be sufficient and there is no difference if the general nurse supervisor assigned one of the nurses to the 9th floor.
No explanation was provided by the DON of the reason why if with two nurses assigned to direct care the residents' needs were satisfied why there are three nurses assigned in some shifts.
2. Review of a summary of monthly nursing staffing for year 2024 it was identified that during January, February, March, April, May, June, July, August and September 2024 hours contact by categorization was always 4.5 no matter resident average census fluctuated between 9 and 19 residents.
3. The Nursing supervisor of SNF (employee #2) was interviewed on 10/29/2024 at 1:00 PM and was asked by the surveyor for the categorization of residents admitted to the facility, the day alleged incidents of abuse and neglect occurs on 10/20/2024. She was asked in relation to the quantity of nursing personnel (LPN's RN's) assigned to be in charge of residents care and distribution accordingly with residents categorization and needs.
The Nursing supervisor stated during interview on 10/29/2024 at 9:30 AM that accordingly with resident categorization performed with a nurse leader in charge of this process on Sunday 20, 2024, the quantity of personnel required for a census of 19 residents, it is 3 LPN's to be assigned in charge of vital signs measure, bath assistance, feeding assistance, grooming assistance and other direct care duties and 2 Register nurses to be in charge of residents assessments, implementation of care plans and other skilled services.
The Nursing supervisor proceed to explain on 10/29/2024 at 9:12 AM that 10/20/2024 was Sunday and on this 7-3 shift of 10/20/2024 and based on need on the hospital nine floor who is a medicine ward one LPN was assigned to the 9th floor. The general nursing supervisor assigned one of the three nurses that had been planned to provide services to SNF residents to the 9th hospital floor. The nurse who moved to the 9th floor was an LPN nurse.
The surveyor asked the Nursing supervisor on 10/29/2024 at 9:40 AM if the movement of an LPN to the 9th floor affects the staffing requirement calculated based on the needs of residents of the SNF. She explain that if the calculation, establish the required quantity of nursing personnel, leadership must be cautious in assigning those personnel to other area, because no matter there is cases that there are occasions in which residents that have advance in outcomes and plan of care goals and are most independent that other residents this does not reflect on the categorization and there is the possibility that the calculation established be less, this is a process and personnel assigned based on categorization of resident needs could require different approaches to comply with rehabilitation process.
The Nursing director stated that the SNF is an outcome goal required rehabilitation scenery, different from an acute care ward.
Nursing supervisor (employee #2) stated on 10/29/2024 at 9:50 AM that SNF must comply with the Payroll Based Journal requirement where there is a process to comply with these requirements that acute care hospital does not need to comply, and that this is a method were SNF need to collect audited and verifiable staffing data that need to be reported to CMS. Nursing supervisor (employee #2) stated on 10/29/2024 at 9:59 AM that regardless one LPN was sent to the 9th floor by the Nursing supervisor on 10/20/2024 shift 7-3, the categorization was not changed but two instead of three nurses were assigned to provide services.
4. On year 2024 documentation of the frequency where personnel assigned to the SNF was re-assigned or sent to other hospital areas was requested by the surveyor to the Nursing supervisor (employee #2) on 10/30/2024 at 9:59 AM.
The documentation presented was reviewed and analyzed with the Nursing supervisor (employee #2) 10/30/2024 at 11:59 AM, after the analysis it was identified that in the past year nursing personnel from the SNF was re-assigned to other hospital areas on 26 occasions. In all the occasions, this occurred on the 7-3 shift on different days of the weeks. The only time when personnel were re-assigned to other hospital areas on the weekend was on 10/20/2024, the day alleged events took place who was Sunday.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected most or all residents
Based on Credential files Reviewed (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that the abuse and neglect training...
Read full inspector narrative →
Based on Credential files Reviewed (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that the abuse and neglect training and the Hand in Hand training was provided to all employees of the Skilled Nursing Facility (SNF) and ensure employees are knowledgeable to react and respond appropriately to protect the resident's right to be free from mental abuse.
Findings include:
During the review of SNF employee Abuse and neglected training and the Hand in Hand Training on 10/30/2024 at 1:00 pm, the following was found:
1.Review of 22 Credential file Review (CFR) on 10/30/2024 at 2:00 PM it was found that 7 out of 22 (31.8%) of nursing personnel working in the SNF did not complete the hand in hand training.
These employees took modules 1, module 2 and module 3; they did not complete module 4 Being with a person with Dementia: Making a Difference and module 5 Preventing and Responding to Abuse. This nursing personnel took these two modules in 2023.
The Hand-in- Hand -A training Series for Nursing Home was taken by an e-learning computer training system that individualized virtual training that the personnel take when they have time to complete the module at different times in the years.
a. CFR #11 took the Hand -in- Hand -A training Series for Nursing Home
Module #1 Understanding the word of Dementia: The person and the disease, was taken on 08/17/2024 and take 3 minutes with 30 seconds to complete them with 100% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking, taken on 08/17/2024 and take 3 minutes with 23 seconds to complete them with 100% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions on 08/17/2024 and take 3 minutes with 01 seconds to complete them with 100% qualification in the SNF.
Module #4 Being with a person with Dementia: Making Difference, taken on 11/08/2023 and take 2 minutes with 15 seconds to complete them with 100% qualification in the maternal and child floor and Nineth floor that was medicine and isolation.
Module #5 Preventing and Responding to abuse taken on 11/08/2023 and takes 2 minutes with 27 seconds to complete them with 100% and qualification in the maternal and child floor and Nineth floor that was medicine and isolation.
This employe was transferred from Hospital setting to the SNF on 06/24/2024.
b. CFR #12 took the Hand -in- Hand -A training Series for Nursing Home
Module #1 Understanding the word of Dementia: The person and the disease, taken on 05/06/2024 and take 2 minutes with 48 seconds to complete them with 90% qualification while at the Hospital Setting.
Module #2 Being with a person with Dementia: Listening and Speaking, taken on 05/06/2024 and take 2 minutes with 43 seconds to complete them with 80% qualification while at Hospital Setting.
Module #3 Being with a person with Dementia: Actions and Reactions, taken on 05/06/2024 and take 3 minutes with 38 seconds to complete them with 100% qualification while at Hospital Setting.
Module #4 Being with a person with Dementia: Making Difference, taken on 11/29/2023 and take 5 minutes with 11 seconds to complete them with a 75% qualification while at the Hospital Setting.
Module #5 Preventing and Responding to abuse, taken on 11/29/2023 and take 2 minutes with 35 seconds to complete them with 87.50% qualification in Hospital Setting.
This employe was transferred from Hospital setting to the SNF on 07/09/2024.
c. CFR #13 take the Hand -in- Hand -A training Series for Nursing Home
Module #1 Understanding the word of Dementia: The person and the disease: taken on 07/20/2024 and take 36 seconds to complete them with a 90% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking; taken on 07/20/2024 and take 43 seconds to complete them with a 80% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions; taken on 07/20/2024 and take 46 seconds to complete them with 90% qualification in the SNF.
Module #4 Being with a person with Dementia: Making Difference taken on 07/29/2023 and take 49 seconds to complete them with a 87.50% qualification in the SNF.
Module #5 Preventing and Responding to abuse; taken on 07/29/2023 and take 2 minutes with 36 seconds to complete them with a 100% qualification in the SNF.
d. CFR #14 take the Hand -in- Hand -A training Series for Nursing Home
Module #1 Understanding the word of Dementia: The person and the disease; taken on 04/13/2024 and take 1 minute with 45 seconds to complete them with 100% qualification in Hospital Setting.
Module #2 Being with a person with Dementia: Listening and
Speaking; taken on 04/13/2024 and take 2 minutes with 03 seconds to complete them with 100% qualification in Hospital Setting.
Module #3 Being with a person with Dementia: Actions and Reactions, taken on 04/13/2024 and take 1 minute with 52 seconds to complete them with 100% qualification in Hospital Setting.
Module #4 Being with a person with Dementia: Making Difference; taken on 03/27/2023 and take 48 seconds to complete them with 100% qualification in the Hospital Setting.
Module #5 Preventing and Responding to abuse; taken on 03/27/2023 and take 24 seconds to complete them with 100% qualification in Hospital Setting.
This employe was removed from Hospital setting to the SNF on 06/10/2024.
e. CFR #15 take the Hand-in- Hand -A training Series for Nursing Home:
Module #1 Understanding the word of Dementia: The person and the disease; taken on 10/16/2024 and take 1 minute with 40 seconds to complete them with 80% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking; taken on 05/18/2023 and take 1 minute with 15 seconds to complete them with 90% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions: taken on 05/18/2023 and take 1 minute to complete them with 80% qualification in the SNF.
Module #4 Being with a person with Dementia: Making Difference; taken on 12/01/2023 and take 1 minute with 58 seconds to complete with 100% qualification in the SNF.
Module #5 Preventing and Responding to abuse, taken on 12/01/2023 and take 6 minutes with 48 seconds to complete them with 100% qualification in the SNF.
f. CFR #16 take the Hand -in- Hand -A training Series for Nursing Home:
Module #1 Understanding the word Dementia: The person and the disease; taken on 09/28/2024 and take 6 minutes with 17 seconds to complete them with 100% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking; taken on 09/28/2024 and take 3 minutes with 49 seconds to complete them with 100% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions on 09/28/2024 and take 3 minutes with 43 seconds to complete them and qualification 100% in the SNF.
Module #4 Being with a person with Dementia: Making Difference on 03/22/2023 and taking 7 minutes with 14 seconds to complete them with 100% qualification in the SNF.
Module #5 Preventing and Responding to abuse; taken on 03/22/2023 and take 1 minute with 50 seconds to complete them with 100% qualification in the SNF.
g. CFR #17 take the Hand-in- Hand -A training Series for Nursing Home:
Module #1 Understanding the word Dementia: The person and the disease; taken on 09/04/2024 and take 4 minutes with 14 seconds to complete them with 90% qualification in the SNF.
Module #2 Being with a person with Dementia: Listening and Speaking; taken on 09/04/2024 and take 4 minutes with 35 seconds to complete them with 90% qualification in the SNF.
Module #3 Being with a person with Dementia: Actions and Reactions; taken on 09/04/2024 and 31 seconds to complete them with 30% qualification in the SNF.
Module #4 Being with a person with Dementia: Making Difference; taken on 11/22/2023 and taking 19 minutes with 16 seconds to complete them with 75% qualification in Hospital setting.
Module #5 Preventing and Responding to abuse; taken on 11/22/2023 and take 1 minute with 49 seconds to complete them with 87.50% qualification in Hospital setting.
This employe was removed from the Hospital setting and transferred to the SNF on 05/25/2024.
2.The facility failed to ensure to provide to all employees of the SNF with the Hand -in- Hand -A training Series for Nursing Home 5 module in sequence time during the years and ensure that the employees are knowledgeable to react and respond appropriately to protect the residents' rights.
3. During an interview with the associated DON (employye #1) on 10/30/2024 at 3:00 PM she states that the facility provides to the nursing personel education relates to abuse and neglect by e-learning computer education system and the hand in hand training by e-learning annual. That in September 2024, they provide the abuse and neglect training presential.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0942
(Tag F0942)
Could have caused harm · This affected most or all residents
Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that Residents Right training is provi...
Read full inspector narrative →
Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that Residents Right training is provided to all employees of the Skilled Nursing Facility (SNF). This deficient practice could affect all residents admitted at the facility.
Findings include:
1. Review of 22 Credential file Review (CFR) on 10/30/2024 from 1:00 PM through at 2:00 PM it was found that 22 nursing personnel working in the SNF did not have the Residents Rights training.
2. The Facility failed to ensure to provide all employees of the SNF with the Residents Right, training to ensure that the employees are knowledgeable to react and respond appropriately to protect the residents' rights.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected most or all residents
Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure an effective training program for all ...
Read full inspector narrative →
Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure an effective training program for all staff that includes, abuse, neglect, exploitation, misappropriation of residents property, dementia management, Residents Right and the Hand in Hand at minimum. This deficient practice was identified in 22 out of 22 credential files reviewed to investigate compliance with training requirements. (CFR #1 through #22).
Findings include:
During the review of SNF employee training on 10/30/2024 from 1:00 PM through 2:00 PM, the following was found:
1.Review of 22 Credential file Review (CFR) on 10/30/2024 at 2:00 PM, it was found that 7 out of 22 (31.8%) of nursing personnel working in the SNF did not complete the hand in hand training. 4 out of 22 (22.7%) of nursing personnel working in the SNF did not complete Pain Management. 4 out of 22 (18.2%) of nursing personnel working in the SNF did not complete Resident experience.
2. The facility failed to provide all employees of the SNF with abuse and neglect training, Pain Management, Residents, Residents and the Hand -in- Hand -A training Series for Nursing Home 5 module in sequence time during the years and ensure that the employees are knowledgeable to react and respond appropriately to protect the residents' right.
May 2024
13 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Report Alleged Abuse
(Tag F0609)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of incidents and complaints during Quality assurance and performance improvement (QAPI) program review and staff...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of incidents and complaints during Quality assurance and performance improvement (QAPI) program review and staff interview performed on 05/17/2024 at 11:20 AM, it was determined that the facility failed to ensure that all alleged violations involving neglect are reported to the State Survey Agency within 5 working days of the incident to verified appropriate corrective action is taken.
Findings include:
Facility policy Title: Abuse and Neglect last updated May 2023 was review on 05/17/2024 at 2:35 PM with QAPI officer (employee #8) Policy clearly stated on the procedures that any incidents/violations that been sustained after investigation that abuse or neglect occur must be reported to the state agency and to the required state nursing examination board agency. This policy did not include provisions who establish the time period when the violation were going to be reported.
1. While the Quality assurance and performance improvement (QAPI) program review was performed on 05/17/24 at 11:23 AM it was referred by the QAPI program officer (employee # 8) refer that 15 days ago it was necessary to activate abuse and neglect protocol due to a situation that occurs on April 29, 2024 with a [AGE] years old female resident who are receiving services for rehabilitation due to a Left Knee Replacement and was admitted on [DATE].
2.Accordingly with information provided by QAPI program officer (employee #9) and Director of Nursing (DON) (employee #10) on 05/17/24 at 11:45 AM on 04/29/24 a nurse took this resident to the shower to receive a bath. DON explain that while resident was in the bathroom, nurse in charge of her did not provide assistance with resident hygiene. Resident is ambulatory enough to reach the bathroom and need minimal assistance bathing herself. However, the nurse did not stay nearby resident room in case the resident needs help.
3. Resident felt bad that nurse did not stay nearby her room in case she needs help. Resident bathed herself and put on her clothes as the best she could with the help of her husband. Resident proceeded to speak with her husband who was there visiting the resident. Resident and her husband proceed to complain about the nurse in charge's way of acting. As result of the situation resident said that felt sad and she did not want to go to receive physical therapy treatment what was she is going to do after taking a bath. Resident stated that she does not want this nurse to be around her or provide any service. Resident also stated that she was afraid to call for assistance to go to the toilet to empty her bladder or bowel because does want that the nurse that did not help her in the shower to provide assistance.
4.Facility refer the resident to neuropsychology services on May 02,2024. Neuropsychology department provides services to resident on May 02,2024,May 03,2024 and May 06, 2024. Main goals for the neuropsychology services were to facilitate collateral training and teach her how to redirect resident fear and anxiety and to reinforce guided relaxation strategies to enhance emotional regulation and positive mood throughout stay at the rehabilitation facility.
Neuropsychology personnel stated on their progress notes that the resident benefit from the replacing of the nurse (with which one resident had the incident) with another nurses and reassurance from other healthcare personnel to ease her apprehension and worry.
5. Accordingly with information provided by QAPI program officer (employee #9) on 05/17/24 at 11:55 AM facility create a temporary committee to investigate the situation (An Ad Hoc committee) and proceed immediately to activate the abuse and neglect protocol and proceed to investigate the incident on May 02, 2024.
6. This Ad Hoc committee investigate the circumstances where the incident occurs and interview personnel in charge, the resident, and her husband. The committee analyzed information collected accordingly with abuse and neglect policies and determined that neglect in relation with the management by the nurse to this resident while she was in the bathroom occurred.
A final determination with the decision was informed to the administrator of the facility on May 06, 2024. Nurse was suspended from work and salary from May 02, 2024 through May 08, 2024 and transferred from the Skilled Nursing Facility (SNF) to the hospital area (this is a SNF located in an hospital).
7. Facility administrator (employee #10) stated on interview on 05/17/24 at 1:00 PM that she receives the determination performed by the Ad Hoc committee on May 06, 2024, and did not notify to the state agency or any local entity (state nursing examination board agency).
8. Facility administrator (employee #10) stated on interview on 05/17/24 at 1:12 PM that she made a phone call on May 09, 2024 to the state Medicare division office and report that an resident complaints in relation with services provided by one of the nurses however did not specify that the situation was investigate by an Ad Hoc committee and that the Ad Hoc committee determine that negligence on the management of the case occur.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, and facility staff interview performed on 05/16/2024 through 05/17/2024 to from 8:30 AM through 4:...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, and facility staff interview performed on 05/16/2024 through 05/17/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to provide services in a manner that respect, and dignity of residents was maintained. This deficiency was identified in 1 out of 19 cases reviewed during initial pool process (Resident #9).
Findings include:
1. Resident #9 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Fracture of Left Femur. During the record review performed on 5/16/2024 at 10:12 AM it was found that resident was presenting periods of disorientation and had urine incontinence.
2. On 05/16/2024 at 12:00 PM resident was observed located in the recreative room seating on a wheelchair were other resident and she receive their lunch trays. When resident #9 is observed eating lunch she was constantly touching her back area and pulling a blue medical surgical pad that personnel put in the seat of the wheelchair. After she touches her back area and the area were the blue pad is located she continues eating from the lunch tray.
3. Nursing supervisor (employee #1) was interview on 05/16/2024 at 1:40 PM and she was ask in relation with resident #9 incontinence and she stated that this resident had been identified with incontinence since admission to the facility that she use disposable diapers and due to the situation that she present large urine spills and this is the reason why personnel put the blue pad on the wheelchair when they were going to move her outside her room or seat her on the wheelchair.
Nursing supervisor (employee #1) was asked by the surveyor on 05/16/2024 at 2:00 PM if there is the possibility that fabric urine spill pad is used with this resident in order to avoid that it was evident (due to the blue pad located on the seat of the wheelchair) that she present incontinence urine spills and maintain resident dignity when she was eating or is located in an area were other residents were eating. Nursing supervisor (employee #1) stated in an interview on 05/16/2024 at 2:10 PM that facility can get fabric urine spill pads to be used with residents who present large urine spills.
4. Facility failed to treat each resident with respect and dignity and provide care and services in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility failed to promote residents' dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, performed on 05/16/2024 through 05/17/2024 to from 8:30 AM through 4:30 PM, it was determined that the fa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, performed on 05/16/2024 through 05/17/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to promote the right to personal privacy and confidentiality for all aspects of care and services. This deficiency was identified in 1 out of 19 cases reviewed during initial pool process (Resident located on room [ROOM NUMBER]-1).
Findings include:
1. Nursing personnel (employee #7) proceed to perform the Dextrostix test to residents located on room [ROOM NUMBER]-1. Before proceeding to puncture resident finger with the lancet, nurse pulled the privacy curtain to provide privacy to resident, however the curtain did not slide completely in a way that covers resident bed area. No matter what the curtain did not slide completely in a way that covers resident area, the nurse proceeds to perform the blood glucose test.
In bed 309-2 it was observed relatives with the resident located in this bed that could see procedure perform to resident located on bed 309-1.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey and dining observations, performed on 05/16/2024 through 05/18/2024 to from 8:30 AM through 4:...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification survey and dining observations, performed on 05/16/2024 through 05/18/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This deficiency was identified in 1 out of 19 cases reviewed during initial pool process (Resident #9).
Findings include:
1. Resident #9 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Fracture of Left Femur. During the record review performed on 5/16/2024 at 10:12 AM it was found that resident was presenting periods of disorientation and had urine incontinence.
2. On 05/16/2024 at 12:00 PM resident was observed located in the recreative room seating on a wheelchair where other residents and she receive their lunch trays. Resident #9 is observed eating lunch without assistance from any personnel. She presents periods of distraction where she put down the cutlery and stop eating. No personnel were observed supervising or cueing the resident when distraction periods were presented. The resident ends up eating approximately 60% of food items in the lunch tray.
3. Facility failed to supervise or assist this resident who becomes easily distracted during meals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations and record reviewed (RR) performed on 05/16/2024 through 05/18/2024 to from 8:30 AM through 4:30 PM...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations and record reviewed (RR) performed on 05/16/2024 through 05/18/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to provide the necessary care and services to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming, and personal care. This deficiency was identified in 1 out of 19 cases reviewed during initial pool process (Resident #9).
Findings include:
1. Resident #9 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Fracture of Left Femur. During the R.R. performed on 5/16/2024 at 10:12 AM it was found that resident was presenting periods of disorientation and had urine incontinence.
2. On 05/16/2024 at 12:00 PM resident was observed located in the recreative room seating on a wheelchair where other residents and she receive their lunch trays. When resident #9 is observed eating lunch she was constantly touching her back area and pulling a blue medical surgical pad that personnel put in the seat of the wheelchair. After she touches her back area and the area where the blue pad is located, she continues eating from the lunch tray. No personnel came to assist the resident or to review if she had a large spill of urine and it was necessary to provide perineal care and change of incontinence items.
2. Facility failed to review if incontinence absorbent pads or disposable pads needed changing and to promote a clean environment where residents eat.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on dining observations, review of policies procedures and facility staff interview performed on 05/16/2024 through 05/17/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility...
Read full inspector narrative →
Based on dining observations, review of policies procedures and facility staff interview performed on 05/16/2024 through 05/17/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that input received from residents and preferences related with food services are met. This deficiency affects 1 out of 19 cases reviewed during dining observations (Resident #77).
Findings include:
1. During dining observations on 05/16/24 at 12:00 PM it was observed that chicken asopao is the main dish in the lunch. It was observed that resident #77 made a bad face when she received the lunch tray.
2. Resident #77 was asked on 05/16/24 at 12:10 PM if she likes chicken asopao. She explains to the surveyor that she like soups and asopao but not as main dish because she is a big woman, she likes to eat and when she eats soup or asopao she gets hungry quickly.
3. Surveyor ask resident #77 on 05/16/24 at 12:15 PM if she wants a substitution in her lunch dinner tray. Resident stated that she wants the substitution and asked if facility had an alternate menu. Surveyor explained to the resident that facility had white rice, stewed beans, and grilled chicken.
4. Nursing personnel are observed assisting residents with lunch trays, however none of them were observed asking residents if they were ok with chicken asopao as main dish.
5. Nursing supervisor was informed on 05/16/24 at 12:50 PM in relation to resident #77 food preferences for lunch. She also was informed that nursing personnel were observed assisting residents with lunch trays, but that none of those personnel asked residents if they were ok with chicken asopao as main dish. Nursing supervisor stated on interview on 05/16/24 at 1:00 PM that it is responsibility of the nursing personnel to ask the residents if everything was ok with their lunch items and to offer food items substitution or change if resident does not want to eat the lunch that kitchen personnel brings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment and facility staff interview performed on 05/16/2024 through 05/17/2024 from 8...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment and facility staff interview performed on 05/16/2024 through 05/17/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to ensure residents to reside and receive services in the facility with reasonable accommodation of residents.
Findings include:
During observational tour the following was observed related with environment in the facility:
1. During the evaluation of room [ROOM NUMBER], it was observed that the clinical staff was transferring the resident of 307A bed from the wheelchair to the bed using the crane. It was observed that the clinical staff invaded the space of the other resident with wheelchair and crane. Resident of #307 B expressed discomfort during the process.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on Physical Environment observation, and facility staff interview performed on 05/16/2024 through 05/17/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to maintain ...
Read full inspector narrative →
Based on Physical Environment observation, and facility staff interview performed on 05/16/2024 through 05/17/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to maintain safe, clean, comfortable, and homelike environment.
Findings include:
1. During visual observation and patient interview on physical environment of the facility bathroom it was observed that lightning fixture mounted on the wall did not provide adequate illumination in the shower area. The light fixture location is lower than the shower curtain which does not permit full light difumination on this area.
2. During visual observation of residents sleeping areas it was noticed that bed platforms behind head rest had accumulation of dust particles.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment performed on 05/16/2024 through 05/17/2024 from 8:00 AM through 5:00 PM, it wa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment performed on 05/16/2024 through 05/17/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed maintain an effective pest control program so that the facility is free of pests.
Findings include:
1. Spiders, spider webs and ants were observed behind curtains in rooms #309, #310, #311, #317 and #319.
2. Particulate, apparent soil was observed in the corner of room [ROOM NUMBER] indicative of an anthill starting to form.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, and facility staff interview performed on 05/16/2024 through 05/17/2024 to from 8:30 AM through 4:...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observations, and facility staff interview performed on 05/16/2024 through 05/17/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to distribute and serve food in accordance with facility established infection control precautions. This deficiency affects 19 out of 19 cases reviewed during dining observations.
Findings include:
1. During dining observations procedures performed on 05/16/24 at 12:00 PM it was identified that kitchen personnel (employee #4) brought the lunch trays in a food warmer cart.
2. Kitchen personnel (employee #5) did not check if resident was in the room before taking out the lunch tray from the food warmer cart. He took off the trays of room [ROOM NUMBER]-2, 308-2 309-2 and 311-1before checking if those residents were in the room. Since residents were not in their room, he returns the lunch tray again to the food warmer.
3. Kitchen personnel return lunch trays to the food warmer cart that had been in the environment of resident's rooms and could be in contact with room surfaces.
4. It was asked to the infection control officer (employee #3) on 05/16/24 at 2:00 PM if is correct that Kitchen personnel (employee #5) return the lunch trays to the food warmer once there had been in the environment of resident's rooms and could be in contact with room surfaces.
5. Infection control officer (employee #3) stated interview on 05/16/24 at 2:10 PM that Kitchen personnel (employee #5) must first review if the resident is in the room before taking the lunch tray from the food warmer cart. She also explains that this way it prevent that lunch trays who could had been in the environment of residents rooms and could be in contact with room surfaces be return to the food warmer cart where there are all the others lunch trays.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on review of Quality Assessment Performance Improvement (QAPI) activities performed on 05/16/24 through 05/17/24 from 8:00 AM till 5:00 PM and interview with the facility QAPI (employee #8) it w...
Read full inspector narrative →
Based on review of Quality Assessment Performance Improvement (QAPI) activities performed on 05/16/24 through 05/17/24 from 8:00 AM till 5:00 PM and interview with the facility QAPI (employee #8) it was determined that facility failed to ensure the participation of all required members on the QAPI committee meetings.
Findings include:
1. During review of facility QAPI committee meetings during year 2023 and the months of February 2024 and April 2024 the following was identified:
Upon review of facility attendance list related to QAPI program committee meeting activities it was identified that the Infection Preventionist did not participate in every QAPI committee meeting.
a. There is no evidence of participation of facility Infection Preventionist on QAPI committee meetings performed on May 25, 2023, September 14, 2023, October 26, 2023, February 15, 2024, and April 15, 2024.
b. During interview on 05/17/24 at 1:30 PM facility QAPI (employee #8) stated that infection control officer gave her the infection control report and discusses with her relevant areas and is her as the QAPI, who present the findings on the QAPI committee meetings.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on infection control observation, and facility staff interview performed on 05/16/2024 through 05/17/2024 from 8:00 AM thr...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on infection control observation, and facility staff interview performed on 05/16/2024 through 05/17/2024 from 8:00 AM through 4:30 PM, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Findings include:
During the medication Pass performed on 5/17/2024 from 8:30 AM till 9:35 AM it was the following:
1. During the medication pass with the registered nurse employee #6 it was observed that nurse did not wash her hand before putting on the non-sterile glove in 4 out of 4 opportunity to wash her hand before gloving hands.
2. During the employee #6 was serving the medication, a piece of paper from the surveyor fell on the floor and the nurse picked it up from the floor and gave it to the surveyor. She continued serving the medication without washing her hands.
3. During the process that the employee #6 performed the medication administration, it was observed that the nurse enter the Medication Administration Record (MAR) to resident room, put them over the dinner table without disinfect the table, then return the MAR to the medication car put over the medication car then put on the medication record, However did not disinfected the medication cart and continue serving the medication.
4. It was observed that employee #6 used a scissor to cut and open the Lidoderma patch without disinfect the scissor previous to used.
5. It was observed that during the nurse served the medication the registered Nurse employe#6 remove the medication from the Pyxie Machine (Automated dispensing cabinet for single and multi-facilities medication management) and put them on the top of the pixie, then put on the medication cart resident box, then when goes to administrate the medication, the Registered Nurse put each individual preserved medication into the medication cup, then when into to the resident room she remove the preserved medication from the cup opened the medication then put them in the same used medication cup, this was a potential cross contamination.
6. The following observations were made while the initial observational tour at the facility is performed on 05/16/24 from 8:00 AM through 12:20 PM:
a. Canister with dirty linen is located at the same side and near 5 wheelchairs on the hallway that starts in room [ROOM NUMBER] and ends in room [ROOM NUMBER]. It was asked to the facility head nurse (employee #2) on 05/16/24 at 10:00 AM if wheelchairs are disinfected and ready to use with residents and she stated that before locating the wheelchairs on this area nursing personnel disinfect them with Caviwipes disinfectant wipes.
b. Kitchen personnel (employee #5) is observed on 05/16/24 from 11:55 AM through 12:20 PM giving residents their lunch trays in room [ROOM NUMBER], # 308, #309, and #310. No nursing personnel were observed providing resident hand hygiene before beginning to eat.
c. Kitchen personnel (employee #5) are observed providing a lunch tray to a resident that was seated on the recreative therapy room. It was observed that this resident begins to eat, and no nursing personnel were observed providing resident hand hygiene before beginning to eat.
d. Resident #9 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Fracture of Left Femur. During the record review performed on 5/16/2024 at 10:12 AM it was found that resident was presenting periods of disorientation and had urine incontinence.
e. On 05/16/2024 at 12:00 PM resident was observed located in the recreative room seating on a wheelchair where other residents and she receive their lunch trays. When resident #9 is observed eating lunch she was constantly touching her back area and pulling a blue medical surgical pad that personnel put in the seat of the wheelchair. After she touches her back area and the area where the blue pad is located, she continues eating from the lunch tray. No nursing personnel were observed providing resident hand hygiene on instances were resident touch her back before she continues eat from her lunch tray. When resident #9 ends eating lunch at 12:50 PM and nursing personnel take away the lunch trays no nursing personnel were observed cleaning and disinfecting table surfaces that resident #9 touch.
7.The following observations were made when nursing personnel (employee #7) perform a Dextrostix blood monitoring to resident located on room [ROOM NUMBER]-1 on 05/17/24 at 8:15 AM:
a. Nursing personnel (employee #7) disinfect glucometer and prepare the lancet and test strip before entering room [ROOM NUMBER]-1. When she entered room [ROOM NUMBER]-1, she left the glucometer case wide open exposing to the environment the lancets, alcohol wipes and test strip bottle.
b. Nursing personnel (employee #7) proceed to perform the Dextrostix test to resident located in room [ROOM NUMBER]-1. When finishes she goes near the resident food tray and puts the breakfast near the resident. No hand hygiene was provided to the resident before giving the breakfast tray.
8. The following observations were made with head nurse (employee #2) on 05/17/24 at 8:55 AM:
a.At the clean linen room it was observed a plastic container used to store clean linen located directly on the floor.
Head nurse (employee #2) stated on interview on 05/17/24 at 9:00 AM that this room had 2 shelves to put the plastic container with clean linens but the shelve located on the higher position is located in a very high position and nursing personnel could not reach the shelve, to put the container when laundry personnel bring the clean linens or to take the container to take off the sheets before use them.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observations of the physical environment and facility staff interview performed on 05/16/2024 through 05/17/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to en...
Read full inspector narrative →
Based on observations of the physical environment and facility staff interview performed on 05/16/2024 through 05/17/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to ensure residents to reside and receive services in the facility with reasonable accommodation.
Findings include:
During observational tour with Engineering Director (employee #10) the following was found:
1. 3 out of 15 wheelchairs were found with loose brake frame
1out of 2 four contact points walking canes with paper creating pressure on suctions cup.
2 of 2 chairs in occupational therapy found with rust.
2. Plastic box used to store linen was observed directly on the floor of the clean linen room
3. Biomedical waste room was observed with the door open and garbage overflowing from the container
4. Two cardboard boxes containing medical equipment (masks and lines) were observed directly on the floor of the respiratory therapy room.
Apr 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey and interview with the Minimum Data Set- MDS coordinator (employee #1) it was identified that th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey and interview with the Minimum Data Set- MDS coordinator (employee #1) it was identified that the facility failed to accurately electronically transmit resident assessment instrument in 1 out of 11 cases reviewed.
Findings include:
Closed Record #11 is a [AGE] year-old female resident admitted [DATE] with a diagnosis of Right Knee Replacement. The resident admission was on 1/30/2023 and discharge home was on 02/09/2023.
On 04/13/23 at 10:35 AM on interview with MDS Coordinator (employee #1) it was identified that the MDS was finished on 02/09/202 and coded to be transmitted was coded as an discharge. When case was transmitted by data entry personnel was transmitted with a code of hospitalization instead a discharge.
The case appears on the Long-Term Care computerized system as a hospitalization and was selected to be review during survey procedures as an hospitalization.
MDS transmission was corrected on 04/12/2022 and transmitted with the correction. Resident assessment validation and entry system report was reviewed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey observation, record review, and interview, with nursing personnel (employee #4) it was identifie...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey observation, record review, and interview, with nursing personnel (employee #4) it was identified that the facility failed to assure that clinical records were accurately documented, completed and contains pertinent information related with health issues that arouse while resident receive rehabilitation services, this deficient practice affect 1 out of 11 sample selection residents (Case review #168)
Findings include:
Record review #168 is a [AGE] year-old female resident admitted [DATE] with a diagnosis of Total Right Hip Replacement and history of and history of Rheumatoid Arthritis. During revision of medications that residents is receiving it was identified that resident had an order for Benadryl 25 mgs PO Stat and Benadryl 25 mgs PO every 6 hour if patient present itch dated 04/08/2023 at 1:00 PM
Case was review and discussed with nursing personnel (employee #4) on 04/12/2023 at 2:00 PM. Employee #4 was informed that nursing progress notes of 04/08/2023 at 1:00 PM did not include information related with resident episode of itch or any allergy. The surveyor asked to nursing personnel (employee #4), information related with indication for Benadryl 25 mgs PO ordered by the physician.
Nursing personnel (employee #4) proceed to seek information about the reason physician order Benadryl 25 mgs PO Stat and Benadryl 25 mgs PO every 6 hour on 04/08/2023 at 1:00 PM. On 04/12/2023 at 3:00 PM nursing personnel (employee #4) stated that this resident apparently presents a rash on the thigh area and that's the physician was notified and that's the reason why physician order Benadryl 25 mgs PO.
Nursing personnel (employee #4) stated on interview on 04/12/2023 at 3:00 PM that nurse in charge of this resident who took the physician order for Benadryl did not document in the progress notes resident assessment and status of skin rash.
Facility policy Title: Documentación [NAME] Cuidado de Enfermería [NAME] Residente was review and discussed with Nursing personnel (employee #4) on 04/12/2023 at 3:35 PM. Policy clearly stated on the procedures that changes in the resident condition that require physician intervention must be documented on the medical record nursing progress note.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on a recertification survey, observations of the physical environment, review of policies procedures and facility staff interview performed on 04/11/2023 through 04/13/2023 to from 8:30 AM throu...
Read full inspector narrative →
Based on a recertification survey, observations of the physical environment, review of policies procedures and facility staff interview performed on 04/11/2023 through 04/13/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, clean, comfortable, and homelike environment. This deficient practice could affect 9 out of 9 residents admitted receiving care at the facility.
Findings include:
1. During visual observation and patient interview on physical environment of the facility room temperature was observed out of ranges of 70 to 75 (º) degrees Fahrenheit. (7 out 9 rooms). 3 out of 9 patients complained about too cold temperature their rooms.
Upon request from surveyors for policies and procedures regarding room temperatures, Clinical Supervisor employee # 3 informed that there are no written policies regarding this matter. She stated that in all shift nurses take room temperature and if out range temperature is found they report through internal system of referrals (evolution system) to engineering department.
At the time of survey temperatures were taken for confirmation:
7A - 70º
8B - 67º
9A - 68º
10B - 68º
11B - 68º
15B - 70º
16B - 69º
17A - 67º
18B - 64º
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Sample Case #164 is a [AGE] year-old female admitted on [DATE] with a diagnosis of Right Artificial Knee Joint. Resident was ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Sample Case #164 is a [AGE] year-old female admitted on [DATE] with a diagnosis of Right Artificial Knee Joint. Resident was admitted for Rehabilitation Services. During the record review performed on [DATE] at 10:01 AM, it was observed that the Baseline Care Plan documentation was incomplete from by physical therapist, occupational therapist and speech therapist in the medical record and the document was not delivered during the first 48 hours of admission. When the Nursing Supervisor (Employee #3) was interviewed on [DATE] at 10:37 AM, indicated that the copy of the Baseline Care Plan was not delivered until it was completely filled out.
9. Sample Case #165 is a [AGE] year-old female admitted on [DATE]with a diagnosis of Right Artificial Hip Joint. Resident was admitted for Rehabilitation Services. During the record review performed on [DATE] at 9:46 AM, the baseline care plan was not found in the medical record. When the Nursing Supervisor (Employee #3) was interviewed on [DATE] at 10:37 AM, indicated that he was in a pilot plan to cover the documentation of the Baseline Care Plan on Thursdays and Fridays.
4. Sample Case review #13 was a [AGE] year-old male admitted on [DATE] with a diagnosis of Right hip fracture, Essential Primary Hypertension, Hyperlipidemia, Arteriosclerotic Heart Disease. The resident was admitted for Rehabilitation Services. During the record review performed on [DATE] at 11:30 AM it was identified that resident death on [DATE]. However, no evidence was found of that the baseline care plans was performed and delivery to the resident. MDS Coordinator (employee #1) stated [DATE] 1:00 PM that in this case #13 was admitted on Monday and the Baseline Care Plan Was performed on Thursday and Fridays and that is the reason why a copy of the baseline care plan is not in the record.
5.Sanple Case Review #169 is a [AGE] year-old male admitted on [DATE] with a diagnosis of Deconditioning Syndrome. Resident was admitted for Rehabilitation Services. During the record review performed on [DATE] at 10:00 AM, it was identified that the Baseline Care Plan was left in the medical record incomplete and was not given to the resident within 48 hours of admission. Nursing Supervisor (employee #3) stated on [DATE] at 10:15 AM that in this case #169 a copy of the baseline care plan was prepared but is not complete and lack the part of the Leisure Activities where the Therapist intervene. Nursing Supervisor (employee #3) stated that this is the reason why a copy of the baseline care plan is not given to the resident.
6. Sample Case review #170 is [AGE] years old admitted on [DATE] with a Diagnosis of Deconditioning Syndrome. Resident was admitted for Rehabilitation Services. During the record review performed on [DATE] at 03:09 PM, it was identified that the Baseline Care Plan was left in the medical record incomplete and was not given to the resident within 48 hours of admission. Nursing Supervisor (employee #3) stated on [DATE] at 3:15 PM that in this case #170 a copy of the baseline care plan was prepared but is not complete and lack the part of the Leisure Activities where the Therapist intervene. Nursing Supervisor (employee #3) stated that this is the reason why a copy of the baseline care plan is not given to the resident.
7. Sample Case review #171 is a [AGE] years old male admitted on [DATE] with a diagnosis of Deconditioning syndrome. Resident was admitted for Rehabilitation Services. During the record review performed on [DATE] at 03:32 PM, it was identified that the Baseline Care Plan was left in the medical record incomplete and was not given to the resident within 48 hours of admission. Nursing Supervisor (employee #3) stated on [DATE] at 3:45 pm that in this case #171 a copy of the baseline care plan was prepared but is not complete and lacks the part of the Leisure Activities where the Therapist intervene. Nursing Supervisor (employee #3) stated that this is the reason why a copy of the baseline care plan is not given to the resident.
Based on a recertification survey, review of eleven medical records, resident interview and interview with the Nursing Supervisor (employee #3) performed from [DATE] thru [DATE], from 9:00 AM thru 4:00 PM, it was determined that the facility failed to develop and implement baseline care plan within 48 hours of a resident's admission in order to promote the continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services. This deficient practice was identified in 9 out of 11 cases reviewed. (RR #13, #164, # 165, # 166, #167, #168, #169, #170, #171).
Findings include:
1. Record review #168 is a [AGE] year-old female resident admitted [DATE] with a diagnosis of Total Right Hip Replacement and history of and history of Rheumatoid Arthritis.
Resident was admitted for rehabilitation services. During the record review performed on [DATE] at 11:00 AM, it was identified that the Baseline Care Plan was left in the medical record and was not given to the resident. Nursing Supervisor (employee #3) stated that in this case #168 a copy of the baseline care plan was prepared but is not complete and lack the part where the social worker intervenes. Nursing Supervisor (employee #3) stated that this is the reason why a copy of the baseline care plan is not given to the resident.
2. Record review #167 is a [AGE] year-old female resident admitted [DATE] with a diagnosis of Intracerebral Hemorrhage. Resident was admitted for rehabilitation services. During the record review performed on [DATE] at 10:30 AM, it was identified that the Baseline Care Plan for this resident was not developed or given to the resident.
3. Record review #166 is a [AGE] year-old male resident admitted [DATE] with a diagnosis of Osteomyelitis in Left Foot. Resident was admitted to intravenous antibiotic and for rehabilitation services. During the record review performed on [DATE] at 11:45 AM, it was identified that the Baseline Care Plan for this resident was not developed or given to the resident.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During the tour in the residents room on 4/12/2023 at 1:30 PM to 3:00 PM, the following was observed:
a. Resident room [ROOM ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During the tour in the residents room on 4/12/2023 at 1:30 PM to 3:00 PM, the following was observed:
a. Resident room [ROOM NUMBER], stained ceiling was observed.
b. Resident room [ROOM NUMBER], the closet door did not close.
Based on a recertification survey, observations of the physical environment, review of policies procedures performed on 04/11/2023 through 04/13/2023 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This deficient practice could affect 9 out of 9 residents admitted receiving care at the facility.
Findings include:
1. During visual observation of facility ceiling tiles were observed in the corridor in front of rooms 307 through 311 with water stains and mold. This was consulted with the Engineering Department Compliance Officer (employee #6) and were informed that this was caused by the AC piping condensation. The ceiling tiles were treated with a putty like material but did not correct the problem because mold was noted in these areas.
2. Physical therapy area - Mold and dust stains were observed on ceiling tiles and around A/C vents. Area above parallels bars therapy apparatus was observed uneven, this was consulted with Engineering Department Compliance Officer (employee #6) which evaluated the area and determined that the lightning fixture was bolted by cables to the structure but cross [NAME] on both sides of the fixture were not bolted.
3. During rooms observation the following was found:
#307 Water stain on ceiling tile
#308 Closet door (B) did not close / water-stained ceiling tile near window.
#309 Rust marks on bathroom ceiling / peeled paint behind bed area / iv stand with rust
#310 Stained mirror (black spots) / wood chair with damaged arm rest
#311 Damaged closet door / peeled paint behind bed (B)
#312 Occupational therapy- broken Formica on kitchen area.
#315 Bed rails were observed with rust on the railing area.
#317 Entrance door with chipping Formica / air conditioning vent presented dust clogs / peeling paint on tiles inside the
shower area/ water stains in ceiling tiles next to entrance and close to windows
#318 Broken ceiling tiles, ceiling tiles are separated from main tee and cross tee / stained bathroom mirror due to water
accumulation / dust clogs on AC screen.
#319 Chipped paint on tiles of shower / chair arm rest peeled.
4. IV stands observed with peeling paint and rust in:
a. room [ROOM NUMBER] A
b. Physical Therapy Area
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0740
(Tag F0740)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey review of policies and procedures, record review, and interview, with Chief Executive Officer (e...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey review of policies and procedures, record review, and interview, with Chief Executive Officer (employee #5) it was identified that the facility failed to have an organized behavioral health care and services program, to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to residents with mental and substance use disorders.
Findings include:
On survey procedures behavioral health care and services program policies and procedures were requested to the facility Chief Executive Officer. During interview on 04/11/2023 at 9:30 AM Chief Executive Officer (employee #5) stated that facility had an agreement with School of Medicine located in [NAME] Puerto Rico and that if facility admit residents who need psychology services school of medicine provide those services. If facility admit residents who need services of the psychiatrist, facility provide those services consulting psychiatry services of the hospital. She also stated that facility did not have policies or procedures with an organized program for behavioral health care and services.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0741
(Tag F0741)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey review of policies and procedures, record review, and interview, with Chief Executive Officer (e...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey review of policies and procedures, record review, and interview, with Chief Executive Officer (employee #5) it was identified that the facility failed to have an organized program with sufficient staff assigned to provide direct services to residents to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to resident's with mental and substance use disorders.
Findings include:
On survey procedures behavioral health care and services program personnel roster schedule were requested to the facility Chief Executive Officer. During interview on 04/11/2023 at 9:39 AM Chief Executive Officer (employee #5) stated that facility had an agreement with School of Medicine located in [NAME] Puerto Rico and that if facility admit residents who need psychology services school of medicine residents provide those services. If facility admit residents who need services of the psychiatrist, facility provide those services consulting psychiatry services of the hospital.
Chief Executive Officer (employee #5) stated that facility did not have an organized roster with personnel assigned to provide psychology or psychiatrist, services to provide direct services to residents to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to resident's with mental and substance use disorders.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0802
(Tag F0802)
Minor procedural issue · This affected most or all residents
Based on recertification survey and interview with kitchen administrative dietitian (employee #2) on 04/12/2023, it was determined that the facility failed to employ sufficient staff with the appropri...
Read full inspector narrative →
Based on recertification survey and interview with kitchen administrative dietitian (employee #2) on 04/12/2023, it was determined that the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service This deficient practice had the potential to affects 11 out of 11 residents admitted receiving at the facility.
Findings include:
On 04/12/2023 at 11:35 AM during the recertification survey, kitchen administrative dietitian (employee #2) provides evidence of the kitchen staffing pattern. During interview on 04/12/2023 at 11:55 AM she explains that accordingly with the calculation of staffing pattern kitchen services need two employees to complete the staffing pattern. She said that one of the employees needed is a production service supervisor and the other employee needed is a warehouse employee. No evidence is provided if facility is currently recruiting personnel for this employment positions.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 32% turnover. Below Puerto Rico's 48% average. Good staff retention means consistent care.
Concerns
- • 38 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $10,839 in fines. Above average for Puerto Rico. Some compliance problems on record.
Bottom line: Mixed indicators with Trust Score of 63/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Damas Hospital Snf's CMS Rating?
CMS assigns DAMAS HOSPITAL SNF an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Puerto Rico, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Damas Hospital Snf Staffed?
CMS rates DAMAS HOSPITAL SNF's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 32%, compared to the Puerto Rico average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Damas Hospital Snf?
State health inspectors documented 38 deficiencies at DAMAS HOSPITAL SNF during 2023 to 2025. These included: 1 that caused actual resident harm, 34 with potential for harm, and 3 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Damas Hospital Snf?
DAMAS HOSPITAL SNF is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 25 certified beds and approximately 17 residents (about 68% occupancy), it is a smaller facility located in PONCE, Puerto Rico.
How Does Damas Hospital Snf Compare to Other Puerto Rico Nursing Homes?
Compared to the 100 nursing homes in Puerto Rico, DAMAS HOSPITAL SNF's overall rating (4 stars) is above the state average of 3.5, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Damas Hospital Snf?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Damas Hospital Snf Safe?
Based on CMS inspection data, DAMAS HOSPITAL SNF has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Puerto Rico. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Damas Hospital Snf Stick Around?
DAMAS HOSPITAL SNF has a staff turnover rate of 32%, which is about average for Puerto Rico nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Damas Hospital Snf Ever Fined?
DAMAS HOSPITAL SNF has been fined $10,839 across 1 penalty action. This is below the Puerto Rico average of $33,187. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Damas Hospital Snf on Any Federal Watch List?
DAMAS HOSPITAL SNF is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.